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  1. Ahmed HMA, Neelakantan P, Dummer PMH
    Int Endod J, 2018 Feb;51(2):164-176.
    PMID: 28635100 DOI: 10.1111/iej.12800
    Thorough knowledge of anatomical complexities of the root canal system has a direct impact on the effectiveness of canal preparation and filling, and is an essential prerequisite for successful root canal treatment. A wide range of complex variations in root canal anatomy exists, including root canal configuration type, developmental anomalies and minor canal morphology such as accessory canals and apical deltas. Accessory canals and apical deltas have been associated with pulp disease, primary canal infection, canal reinfection and post-treatment disease. The current definitions of accessory canal anatomy are not standardized and potentially confusing. Given their role in endodontic disease and their impact on treatment outcomes, there is a need to have a simple classification of their anatomy to provide an accurate description of their position and path from the canal to the external surface of the root. The purpose of this article is to introduce a new system for classifying accessory canal morphology for use in research, clinical practice and training.
  2. Baloch N, Atif M, Rashid RH, Hashmi PM
    Malays Orthop J, 2015 Nov;9(3):55-57.
    PMID: 28611912 DOI: 10.5704/MOJ.1511.008
    Toe-tourniquet syndrome is a rare and commonly misdiagnosed condition caused by a hair or a fiber wrapped around digits (fingers and toes). A four months baby girl who was crying and presented with redness and swelling at her 2nd and 3rd toes of right foot. Child had red and swollen 2nd and 3rd toes of right foot with hair end protruding through wounds. Constricting hairs were cut and removed. Toetourniquet syndrome is a rare entity which is caused by hair wrapped around a toe or a digit. Diagnosis is mostly clinical. In order to prevent this condition to happen, education of parents and clinicians is a cornerstone.
  3. Nagendrababu V, Duncan HF, Dummer PMH
    Int Endod J, 2020 Apr;53(4):437-439.
    PMID: 32170984 DOI: 10.1111/iej.13272
  4. Lee PM, Chang CT, Yusoff ZM
    Int J Clin Pharm, 2021 Feb;43(1):46-54.
    PMID: 32524510 DOI: 10.1007/s11096-020-01070-9
    Background Tyrosine kinase inhibitors have been demonstrated to improve the survival of patients with chronic myeloid leukaemia. However, medication adherence is vital for patients on chronic treatment. Objective The objective of the current study was to evaluate response to treatment, adherence by patients to tyrosine kinase inhibitors and factors associated with adherence and response. Setting A haematology clinic in a regional referral hospital in Malaysia. Method Patients aged ≥ 13 years who had been on imatinib or nilotinib for ≥ 12 months were included in this cross-sectional study. An optimal response was defined as the achievement of major molecular response at 12 months of treatment. Patient medication adherence was determined using the average medication possession ratio based on the dispensing records. The patients were considered adherent if the medication possession ratio was > 90%. Multiple logistic regression was performed to evaluate the factors associated with adherence. The association of adherence with molecular response was analysed by univariate logistic regression. Main outcome measure The primary outcome measures were the proportion of patients who achieved optimal response and the medication possession ratio. Results A total of 151 patients were screened, and 71 patients were included. Twenty-eight patients (39%) achieved major molecular response at 12 months of treatment. The median time to achieve this was 15.5 months (an interquartile range of 15). The mean medication possession ratio for imatinib and nilotinib was 0.94 (± 0.14) and 0.96 (± 0.10), respectively, but this difference was without statistical significance (t  =  - 0.517, p  =  0.610). Nausea and vomiting (odds ratio [OR] of 0.25, 95% confidence interval [CI]: 0.07-0.83, p  =  0.023) and disease phase at diagnosis (OR of 0.20, 95% CI 0.04-1.06, p  =  0.059) were associated with patient adherence. An association was not found between patient adherence and molecular response (OR of 1.03, 95% CI 0.35-3.09, p  =  0.956). Conclusion The patients in this study demonstrated a relatively deep molecular response and optimal adherence. Nevertheless, one fourth of them were noncompliant with imatinib. Therefore, active interventions are warranted to prevent treatment-associated adverse events and improve adherence.
  5. Ahmed HMA, Dummer PMH
    Int Endod J, 2018 Apr;51(4):389-404.
    PMID: 29023779 DOI: 10.1111/iej.12867
    Understanding the normal anatomical features as well as the more unusual developmental anomalies of teeth, roots and root canals is essential for successful root canal treatment. In addition to various types of root canal configuration and accessory canal morphology, a wide range of developmental tooth, root and canal anomalies exists, including C-shaped canals, dens invaginatus, taurodontism, root fusion, dilacerations and palato-gingival grooves. There is a direct association between developmental anomalies and pulp and periradicular diseases that usually require a multidisciplinary treatment approach to achieve a successful outcome. A number of classifications have categorized tooth, root and canal anomalies; however, several important details are often missed making the classifications less than ideal and potentially confusing. Recently, a new coding system for classifying root, root canal and accessory canal morphology has been introduced. The purpose of this article is to introduce a new system for classifying tooth, root and canal anomalies for use in research, clinical practice and training, which can serve as complementary codes to the recently described system for classifying root, as well as main and accessory canal morphology.
  6. M. Jayaprakash, R. Nagarajan, P. M. Velmurugan, L. Giridharan, girilogu@yahoo.com, B. Urban
    MyJurnal
    The composite nature of Ennore Creek, receiving polluted waters from Buckingham canal, River Kortalaiyar, and the presence of numerous industries rapidly degrade the coastal environment. In this study, multivariate statistical technique was used to assess the nature of pollution and to identify the factors responsible for the enrichment of trace metals in the creek sediments. Forty samples were collected during pre- and post-monsoon periods to evaluate the seasonal variations on the concentration of trace metals in the sediments. The results indicate that not much seasonal variation exists in the concentration of trace metals in the sediments of Ennore creek. Results of the cluster analysis illustrate that the enrichment of trace metals was mainly from anthropogenic sources. Meanwhile, correlation coefficient among the metals reveals that some of the metals (Fe and Al) derived were of natural origin. The complex data matrix of the sediment were interpreted after reduction to three factors and the results illustrate the extent of the influence of anthropogenic activities. The spatial distribution diagrams demonstrate and demarcate the region of enrichment of metals in the sediments of Ennore creek.
  7. Vasanthan P, Tang LPM, Maryam MZ, Mohd Jazlan MA, Narayanan P
    JUMMEC, 2002;7:147-149.
    This study is aimed at determining whether there exists a correlation between the relative dimensions of the nose and the face. Through this study, we hoped to give a normal range for the different races in Malaysia. We randomly chose 100 Malay, 50 Chinese and 50 Indian subjects. We chose equal numbers of male and female subjects, mainly in their 20's and 30's. There is a correlation between the length of the nose and the face among Malays, with 78% of the subjects measured having a nose:face ratio of less than 0.27. There is also a correlation between the breadth of the nose and the face among Malays, with 670/0 of the subjects having a ratio of less than 0.28. Similar correlations were found with Chinese and Indian subjects. The length and breadth of the nose in relation to the face is greater in males than in females. Further research is required before conclusive evidence is found for the existence or non existence of a correlation between the length and breadth of the nose and face in the different races in Malaysia. KEYWORDS: Correlation, length, breadth, nose, nace, different races.
  8. Yusof AP, Yusoff NH, Suhaimi FW, Coote JH
    Auton Neurosci, 2009 Jun 15;148(1-2):50-4.
    PMID: 19349212 DOI: 10.1016/j.autneu.2009.03.005
    The aim of the present study was to determine if paraventricular-spinal vasopressin neurones participate in the sympatho-inhibitory effects of systemically administered atrial natriuretic peptide (ANP) on renal sympathetic nerve activity (RSNA). Experiments were carried out on male Sprague-Dawley rats anesthetized with 1.3 g/kg urethane. Changes in mean arterial pressure (mm Hg), heart rate (beats per minute) and RSNA (%) were measured following intravenous bolus administration of ANP (250 ng, 500 ng and 5 microg). Intrathecal application of selective V 1a receptor antagonist was performed to test for the involvement of supraspinal vasopressin pathways in mediating the effect on sympathetic outflow evoked by intravenous ANP administration. The results obtained demonstrated that both low and high doses of ANP caused renal sympathoinhibition (250 ng; - 7.5 +/- 1%, 500 ng; - 14.2 +/- 1%, 5 microg; - 16.4 +/- 2%), concomitant with vasodilation and bradycardia. After spinal vasopressin receptor blockade, the inhibitory effects of ANP were prevented and there was a small renal sympatho-excitation (250 ng; + 1.7 +/- 0.2%, 500 ng; + 6.1 +/- 0.03%, 5 microg; + 8.0 +/- 0.03%, P < 0.05). Therefore, the renal sympathetic nerve inhibition elicited by circulating ANP is dependent on the efficacy of a well established supraspinal vasopressin pathway. Since supraspinal vasopressin neurones without exception excite renal sympathetic neurones, it is suggested that ANP elicits this effect by activating cardiac vagal afferents that inhibit the spinally projecting vasopressin neurones at their origin in the paraventricular nucleus of the hypothalamus.
  9. Endersby NM, McKechnie SW, Ridland PM, Weeks AR
    Mol Ecol, 2006 Jan;15(1):107-18.
    PMID: 16367834
    The diamondback moth, Plutella xylostella, is renowned for developing resistance to insecticides and causing significant economic damage to Brassica vegetable crops throughout the world. Yet despite its economic importance, little is known about the population structure and movement patterns of this pest both at local and regional scales. In Australia, the movement patterns and insecticide resistance status of P. xylostella infesting canola, vegetables, forage brassicas and weeds have fundamental implications for the management of this pest. Here we use six polymorphic microsatellite loci to investigate population structure and gene flow in Australian populations of P. xylostella. Samples of P. xylostella from New Zealand, Malaysia, Indonesia and Kenya were also scored at these loci. We found no evidence of population structure within Australia, with most populations having low inbreeding coefficients and in Hardy-Weinberg equilibrium. In addition, a sample from the North Island of New Zealand was indistinguishable from the Australian samples. However, large genetic differences were found between the Australia/New Zealand samples and samples from Kenya, Malaysia and Indonesia. There was no relationship between genetic distance and geographic distance among Australian and New Zealand samples. Two of the loci were found to have null alleles, the frequency of which was increased in the populations outside the Australia/New Zealand region. We discuss these results with reference to insecticide resistance management strategies for P. xylostella in Australia.
  10. Azizi AB, Lim MP, Noor ZM, Abdullah N
    Ecotoxicol Environ Saf, 2013 Apr;90:13-20.
    PMID: 23294636 DOI: 10.1016/j.ecoenv.2012.12.006
    Experiments were conducted to remove heavy metals (Cr, Cd, Pb, Cu and Zn) from urban sewage sludge (SS) amended with spent mushroom compost (SMC) using worms, Lumbricus rubellus, for 105 days, after 21 days of pre-composting. Five combinations of SS/SMC treatments were prepared in triplicate along with a control for each treatment in microcosms. Analysis of the earthworms' multiplication and growth and laboratory analysis were conducted during the tenth and fifteenth week of vermicomposting. Our result showed that the final biomass of earthworms (mg) and final number of earthworms showed significant differences between treatments i.e. F=554.70, P=0.00 and F=729.10, P=0.00 respectively. The heavy metals Cr, Cd and Pb contained in vermicompost were lower than initial concentrations, with 90-98.7 percent removal on week ten. However, concentrations of Cu and Zn, that are considered as micronutrients, were higher than initial concentrations, but they were 10-200-fold lower than the EU and USA biosolid compost limits and Malaysian Recommended Site Screening Levels for Contaminated Land (SSLs). An increment of heavy metals were recorded in vermicompost for all treatments on week fifteen compared to week ten, while concentration of heavy metals in earthworms' tissue were lower compared to vermicompost. Hence, it is suggested that earthworms begin to discharge heavy metals into their surroundings and it was evident that the earthworms' heavy metals excretion period was within the interval of ten to fifteen weeks.
  11. Lim JMH, Tayob Y, O'Brien PM, Shaw RW
    Med J Malaysia, 1997 Dec;52(4):377-81.
    PMID: 10968114
    The pregnancy outcome of 33 women with gestational diabetes who were treated with glibenclamide and changed to insulin if glibenclamide failed, were compared with the pregnancy outcome of 21 women with gestational diabetes treated conventionally with insulin. The pregnancy outcome, with regard to the overall glycaemic control, rates of preterm labour, neonatal hypoglycaemia, fetal macrosomia, perinatal morbidity and mortality, were not statistically different between the two treatment groups. The limited number of women studied, and the non-random allocation of these women to each treatment group however, could have influenced these results. There were a few observed differences in the pregnancy outcome between the two treatment groups, which although were not statistically significant, caused some concern. In particular we noted an increased rate of fetal macrosomia in the glibenclamide treated group, which in theory could have been drug mediated.
  12. Chung AY, Eggleton P, Speight MR, Hammond PM, Chey VK
    Bull. Entomol. Res., 2000 Dec;90(6):475-96.
    PMID: 11107250
    The diversity of beetle assemblages in different habitat types (primary forest, logged forest, acacia plantation and oil palm plantation) in Sabah, Malaysia was investigated using three different methods based on habitat levels (Winkler sampling, flight-interception-trapping and mist-blowing). The overall diversity was extremely high, with 1711 species recorded from only 8028 individuals and 81 families (115 family and subfamily groups). Different degrees of environmental changes had varying effects on the beetle species richness and abundance, with oil palm plantation assemblage being most severely affected, followed by acacia plantation and then logged forest. A few species became numerically dominant in the oil palm plantation. In terms of beetle species composition, the acacia fauna showed much similarity with the logged forest fauna, and the oil palm fauna was very different from the rest. The effects of environmental variables (number of plant species, sapling and tree densities, amount of leaf litter, ground cover, canopy cover, soil pH and compaction) on the beetle assemblage were also investigated. Leaf litter correlated with species richness, abundance and composition of subterranean beetles. Plant species richness, tree and sapling densities correlated with species richness, abundance and composition of understorey beetles while ground cover correlated only with the species richness and abundance of these beetles. Canopy cover correlated only with arboreal beetles. In trophic structure, predators represented more than 40% of the species and individuals. Environmental changes affected the trophic structure with proportionally more herbivores (abundance) but fewer predators (species richness and abundance) in the oil palm plantation. Biodiversity, conservation and practical aspects of pest management were also highlighted in this study.
  13. Rogatcheva MB, Borodin PM, Oda SI, Searle JB
    Genome, 1997 Feb;40(1):18-24.
    PMID: 9061910
    A high-resolution G-banding technique was used to identify five metacentrics that characterize Suncus murinus from Sri Lanka. These metacentrics were shown to be the product of Robertsonian fusion of acrocentric chromosomes identical to those in the standard karyotype defined by M.B. Rogatcheva et al. Two of the metacentrics in the Sri Lankan shrews (Rb(10.12) and Rb(14.15)) were the same as those reported by C.H. Sam et al. in Malayan populations of S. murinus. This finding provides strong support for the suggestion of T.H. Yosida that metacentric-carrying shrews colonized Malaya from Sri Lanka and hybridized with individuals of standard karyotype, generating the Robertsonian polymorphism now observed. In addition to the Robertsonian variation in S. murinus, we have used our high resolution technique (G- and C-banding) to characterize variants on chromosome 7, the X chromosome, and the Y chromosome.
  14. Yusof MY, Thevissen PW, Fieuws S, Willems G
    Int J Legal Med, 2014 Mar;128(2):329-33.
    PMID: 23370574 DOI: 10.1007/s00414-013-0825-8
    The applicability of the Willems et al. model was verified on a collected sample of Malay (Malaysian nationality) children. This sample was split in a reference sample to develop a Malay-specific prediction model based on the Willems et al. method and in a test sample to validate this new developed model. Next, the incorporation of third molars into this model was analyzed. Panoramic radiographs (n = 1,403) of Malay children aged between 4 and 14.99 years (n = 702) and subadults aged between 15 and 23.99 years (n = 701) were collected. The left mandibular seven permanent teeth of the children were scored based on the staging technique described by Demirjian and converted to age using the Willems et al. method. Third molar development of all individuals was staged based on the technique described by Gleiser and Hunt modified by Kohler. Differences between dental age and chronological age were calculated and expressed in mean error (ME), mean absolute error (MAE), and root mean square error (RMSE). The Willems et al. model verified on the collected Malay children overestimated chronological age with a ME around 0.45 year. Small differences in ME, MAE, and RMSE between the verified Malay-specific prediction model and the Willems et al. model were observed. An overall neglected decrease in RMSE was detected adding third molar stages to the developed permanent teeth model.
  15. Ordinola-Zapata R, Peters OA, Nagendrababu V, Azevedo B, Dummer PMH, Neelakantan P
    Int Endod J, 2020 Jan;53(1):36-52.
    PMID: 31454086 DOI: 10.1111/iej.13210
    AIM: To report the most common terminology used in titles of scientific papers published in the International Endodontic Journal (IEJ) and Journal of Endodontics (JOE) between 1980 and 2019 and to identify the most-cited papers in these journals.

    METHODOLOGY: The Web of Science database was searched to retrieve all the manuscripts published in the IEJ and JOE between 1980 and 2019. The articles were analysed using the VOS viewer software and the terms within the titles extracted. The top-10 terms were categorized according to the number of occurrences and the decade of publication. Maps were created using the text data for each decade of publication. Classic papers were identified when the number of citations was >400. During the same period of time, highly cited studies were identified including the authors, institutions and countries associated with these papers.

    RESULTS: Terms such as canal, molar and periapical lesion were the most commonly used in titles between 1980 and 1999. The terms instruments, expression, case report and cell were the most often terms used between 2000 and 2019. During the last 10 years, an increase in the number of reviews and papers on cone beam computed tomography occurred. The organizations with the largest number of citations in each decade were University of São Paulo, University College London, Loma Linda University and United States Army. The country with the largest number of citations and greatest number of top 10 and top 100 manuscripts was the United States. A paper had to be associated with more than 167 citations to be included in the top-100 most-cited list; at least 14 papers met the criteria to be categorized as a citation classic (>400 citations).

    CONCLUSION: While many diverse areas of endodontics have been explored in the last 40 years within the IEJ and JOE, only a relatively few topics are highly cited and can be considered as classics.

  16. Ahmad P, Dummer PMH, Noorani TY, Asif JA
    Int Endod J, 2019 Jun;52(6):803-818.
    PMID: 30667524 DOI: 10.1111/iej.13083
    AIM: To analyse the main characteristics of the top 50 most-cited articles published in the International Endodontic Journal from 1967 to 2018.

    METHODOLOGY: The Clarivate Analytics' Web of Science 'All Databases', Elsevier's Scopus, Google Scholar and PubMed Central were searched to retrieve the 50 most-cited articles in the IEJ published from April 1967 to December 2018. The articles were analysed and information including number of citations, year of publication, contributing authors, institutions and countries, study design, study topic, impact factor and keywords was extracted.

    RESULTS: The number of citations of the 50 selected papers varied from 575 to 130 (Web of Science), 656 to164 (Elsevier's Scopus), 1354 to 199 (Google Scholar) and 123 to 3 (PubMed). The majority of papers were published in the year 2001 (n = 7). Amongst 102 authors, the greatest contribution was made by four contributors that included Gulabivala K (n = 4), Ng YL (n = 4), Pitt Ford TR (n = 4) and Wesselink PR (n = 4). The majority of papers originated from the United Kingdom (n = 8) with most contributions from King's College London Dental Institute (UK) and Eastman Dental Hospital, London. Reviews were the most common study design (n = 19) followed by Clinical Research (n = 16) and Basic Research (n = 15). The majority of topics covered by the most-cited articles were Outcome Studies (n = 9), Intracanal medicaments (n = 8), Endodontic microbiology (n = 7) and Canal instrumentation (n = 7). Amongst 76 unique keywords, Endodontics (n = 7), Mineral Trioxide Aggregate (MTA) (n = 7) and Root Canal Treatment (n = 7) were the most frequently used.

    CONCLUSION: This is the first study to identify and analyse the top 50 most-cited articles in a specific professional journal within Dentistry. The analysis has revealed information regarding the development of the IEJ over time as well as scientific progress in the field of Endodontology.

  17. Sok SPM, Ori D, Nagoor NH, Kawai T
    Crit. Rev. Immunol., 2018;38(4):279-301.
    PMID: 30806244 DOI: 10.1615/CritRevImmunol.2018026540
    The innate immune system serves as the first line of defense to protect the host from pathogen infection. As a first step, the pattern recognition receptors (PRRs) recognize pathogen-associated molecular patterns (PAMPs), such as non-self DNA derived from pathogens, and damage-associated molecular patterns (DAMPs), such as self DNA released from damaged or injured cells. Sensing of such DNAs elicits innate immune responses through the production of type I interferons (IFNs) and proinflammatory cytokines resulting from the activation of interferon regulatory factor 3 (IRF3) and nuclear factor kappa B (NF-κB), respectively. These cytokines are key players in interlinking innate and adaptive immune responses. However, defects in DNA sensors and their signaling cascades lead to dysregulation of immune responses, autoimmune diseases, and cancer progression. Here we provide an update on DNA signaling pathways in response to pathogen infection and cell injury, and on the roles of regulators in governing the immune system and maintaining host homeostasis. We also discuss the evasion of immunosurveillance by pathogens.
  18. Ahmad P, Dummer PMH, Chaudhry A, Rashid U, Saif S, Asif JA
    Int Endod J, 2019 Sep;52(9):1297-1316.
    PMID: 31009099 DOI: 10.1111/iej.13131
    AIM: To identify and analyse the main features of the top 100 most-cited randomized controlled trials, systematic reviews and meta-analyses published in endodontic journals from 1961 to 2018.

    METHODOLOGY: The Clarivate Analytics' Web of Science 'All Databases' was used to search and analyse the 100 most frequently cited randomized controlled trials, systematic reviews and meta-analyses having 'randomized', 'randomised', 'randomized controlled', 'randomised controlled', 'randomized controlled trial', 'randomized controlled trials', 'clinical trial', 'systematic', 'systematic review', 'meta-analysis', and 'meta-analyses' in the title section. The 'International Endodontic Journal', 'Journal of Endodontics', 'Oral Surgery Oral Medicine Oral Pathology Oral Radiology and Endodontology', 'Australian Endodontic Journal', 'Endodontics & Dental Traumatology', 'Endo-Endodontic Practice Today' and 'European Endodontic Journal' were included in the publication name section. After ranking the articles in a descending order based on their citation counts, each article was cross-matched with the citation counts in Elsevier's Scopus and Google Scholar. The articles were analysed, and information on citation counts, citation density, year of publication, contributing authors, institutions and countries, journal of publication, study design, topic of the article and keywords was extracted.

    RESULTS: The citation counts of the 100 most-cited articles varied from 235 to 20 (Web of Science), 276 to 17 (Scopus) and 696 to 1 (Google Scholar). The year in which the top 100 articles were published was 2010 (n = 13). Among 373 authors, the greatest number of articles was associated with three individuals namely Reader A (n = 5), Beck M (n = 5) and Kvist T (n = 5). Most of the articles originated from the United States (n = 24) with the greatest contribution from Ohio State University (USA) (n = 5). Randomized controlled trials were the most frequent study design (n = 45) followed by systematic reviews (n = 30) with outcome studies of root canal treatment being the major topic (n = 35). The Journal of Endodontics published the largest number of included articles (n = 70) followed by the International Endodontic Journal (n = 27). Among 259 unique keywords, meta-analysis (n = 23) and systematic review (n = 23) were the most frequently used.

    CONCLUSION: This study has revealed that year of publication had no obvious impact on citation count. The bibliometric analysis highlighted the quantity and quality of research, and the evolution of scientific advancements made in the field of Endodontology over time. Articles before 1996, that is prior to the CONSORT statement that encouraged authors to include specific terms in the title and keywords, may not have been included in this electronic search.

  19. Jakovljevic A, Duncan HF, Nagendrababu V, Jacimovic J, Milasin J, Dummer PMH
    Int Endod J, 2020 Oct;53(10):1374-1386.
    PMID: 32648971 DOI: 10.1111/iej.13364
    BACKGROUND: The existence of an association between cardiovascular diseases (CVDs) and apical periodontitis (AP) remains unclear because results obtained from previous clinical studies and reviews are inconsistent or inconclusive.

    OBJECTIVE: To conduct an umbrella review to determine whether there is an association between CVDs and the prevalence of AP in adults.

    METHODS: The protocol of the review was registered in the PROSPERO database (CRD42020185753). The literature search was conducted using the following electronic databases: Clarivate Analytics' Web of Science Scopus, PubMed and Cochrane Database of Systematic Reviews, from inception to May, 2020, with no language restrictions. Systematic reviews with or without meta-analysis that evaluated the association between CVDs and AP were included. Other types of studies, including narrative reviews, were excluded. Two reviewers independently performed a literature search, data extraction and quality assessment of included studies. Any disagreements or doubts were resolved by a third reviewer. The quality of the reviews was assessed using the AMSTAR 2 tool (A measurement tool to assess systematic reviews), with 16 items. A final categorization of the systematic reviews classified each as of 'high', 'moderate', 'low' or 'critically low' quality.

    RESULTS: Four systematic reviews were included in the current review. Three reviews were graded by AMSTAR 2 as 'moderate' quality, whereas one review was graded as 'critically low' quality.

    DISCUSSION: Only one systematic review included a meta-analysis. Substantial heterogeneity amongst the primary studies included within each systematic review was notable in preventing a pooled analysis.

    CONCLUSIONS: From the limited 'moderate' to 'critically low' quality evidence available, the current umbrella review concluded that a weak association exists between CVDs and AP. In the future, well-designed, longitudinal clinical studies with long-term follow-up are required.

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